Apgar Score: the five signs evaluated

Apgar Score: the five signs evaluated

Apgar Score: the five signs

Right after birth, the health of a newborn baby is evaluated using the Apgar score, in which five factors are measured on a scale of zero to two. These scores are then added to give the final value which ranges from zero to ten. Thus, the overall health of the newborn baby can be assessed. This test is conducted in the delivery room on a newborn baby and helps to determine whether the baby is in good health, after birth. The Apgar score was developed in 1952 by an anesthesiologist named Virginia Apgar. The term Apgar is also an acronym derived from the five factors that are assessed, which are appearance, pulse, grimace, activity and respiration.

  • Appearance - In this, the skin color of the newborn baby is checked. This includes evaluation of whether the baby is pale all over or blue, is the baby's skin color pink or are the extremities pink.
  • Pulse - After birth, the heart rate of the baby is checked. This includes evaluation whether the heart rate is absent or is it slow or fast.
  • Grimace response - After birth, the reflex irritability of the newborn baby is checked. This includes evaluating whether the baby responds to stimulation, or when stimulated does the baby pull away or does the baby give a feeble cry and grimace.
  • Activity - The muscle tone of the baby is checked. This includes evaluating whether the baby exhibits any activity such as flexion or does the baby have flexed arms and legs in which extension is resisted.
  • Respiration - The breathing effort and the breathing rate of the newborn baby is checked. This includes evaluating the breathing of the baby, whether it is weak, or if the respiratory rate is irregular or is the crying really strong.  

This test is used to assess whether the newborn baby has any trouble with the heart or breathing. The assessment of health of the newborn baby should be done well so that there are no chances of future complications. If any future treatment is required, then the doctors should take the right measures and provide proper treatment for the baby.

This test is performed after birth at one minute and then again at five minutes. It is a quick test. Usually how well the birthing process has been tolerated by the baby can be determined by the one minute Apgar test and how well the baby is doing outside the womb of the mother can be determined by the five minute Apgar score.

The test can be done 10 minutes after birth, but this may be needed very rarely.

Apgar Score Chart

In the delivery room, this is the first test on every newborn baby. It evaluates the physical condition of the baby and determines whether any immediate emergency medical care is needed. 

One-minute Apgar score - After birth, the doctor has one minute to determine whether the baby needs any imminent medical attention. This is the first Apgar score. If the score is between 7 and 10, then it means that the baby is doing fine and more than usual care is not needed. Mouth and nose suction along with oxygen is required to help the child breathe if the score is between 4 to 6. To save the baby’s life, resuscitation is needed if the score is 3 or less than 3. Among premature babies and those delivered through cesarean section, it is common to get a low Apgar score at one minute. However, it does not mean that eventually the baby will be fine.

Five-minute Apgar score - Using the same scoring system, the doctor evaluates the baby again. This is to see the progress of the baby. At five minutes, if the Apgar score is between 7 to 10, then it is normal. However, serious medical attention and further evaluation is needed, if the Apgar score is 6 or less.

Importance of the Five Signs in Apgar Score

The Apgar score that assesses five factors helps to determine the health of the baby right after birth and is calculated on a scale of zero to ten. More the score, better is the health of the baby. Generally, a score of 7, 8 or 9 is considered normal and indicates the baby is in good health.

Since most babies have blue hands or feet right after birth, hence it is quite unusual for a newborn to get a score of 10. But if the Apgar score is below seven, the baby has health problems and may need medical attention. The Apgar score, also referred to as newborn scoring, is very important as it is an assessment of the baby's health right after birth. On a scale of 0 to 2, each of the five elements are measured. If the score is high, it may indicate optimal health.

  • Appearance - it indicates that skin color should not be blue and should be normal
  • Pulse - the heart rate per minute should be more than 100 beats
  • Grimace response - in response to stimulation, the child should withdraw or cry vigorously
  • Activity - the baby should not limp and should be moving around
  • Respiration - if the baby cries strongly, then it will indicate a healthy baby. If the breathing is irregular, it may indicate a problem.

Rating of the Five Tasks

This test is done by the nurse, midwife or the doctor. The baby is examined by the doctor for the following factors :

  • Heart rate
  • Breathing effort
  • Muscle tone
  • Skin color
  • Reflexes

With a score of 0, 1 or 2 each of them is assessed.

  • Heart rate - One of the most important assessments is of heart rate. With the help of a stethoscope, the heart rate is evaluated. 120 to 160 beats per minute is the normal heart rate at birth.
    • The infant will score 0 if there is no heart rate
    • The infant scores 1 if the heart rate is less than 100 beats per minute
    • The infant scores 2 if the heart rate is greater than 100 beats per minute
  • Breathing effort -  At birth, a newborn baby should gasp and begin to breathe. 
    • The respiratory score is 0 if the infant is not breathing.
    • For respiratory effort the infant scores 1 if the respiration is slow or irregular. If the breathing is irregular, then it may mean that the body is lacking in oxygen and has an infection. It could also mean damage to the central nervous system or respiratory drive has got depressed due to the anesthesia that was given to the mother during the childbirth.
    • The respiratory score is 2 if the infant cries well.
  • Muscle tone - At birth, the infant should move his arms and legs.
    • The infant scores 0 if the muscles are loose and floppy.
    • The infant scores 1 if there is some muscle tone. Lack of oxygen, trauma to the central nervous system or drugs given during childbirth to the mother may cause lack of oxygen which may cause limpness or poor muscle tone.
    • The infant scores 2 if there is active motion shown by the infant.
  • Skin color 
    • The infant scores 0 if the skin color is pale blue. If the baby has overall bluish color, then it may indicate that there is some problem with heart or lungs. Maybe the airway of the baby is blocked or maybe amniotic fluid has been inhaled by the baby.
    • The infant scores 1 if the body is pink and the extremities are blue.
    • The infant will score 2 if the entire body is pink.
  • Grimace response - Response to stimulation is termed as reflex irritability or grimace response. The stimulation can be a mild pinch. By inserting a tuber into the throat through a nostril, the infant is stimulated at birth. Either the infant should sneeze, cough or grimace.
    • The infant scores 0 if there is no reaction.
    • The infant scores 1 if there is grimacing.
    • The infant scores 2 if there is grimacing and a vigorous cry, coughing and sneezing.

10 is the highest possible total Apgar score. If the Apgar score is 7 at one minute of age, then it is not unusual. Later, such babies have better breathing and healthier skin too. With the help of the information provided by the Apgar score, medical personnel can take immediate measures to ensure survival of a newborn.

Heart Rate and Apgar at birth

The heart beat is 100 to 160 beats per minute for a healthy term baby. During the first hours after birth, the heartbeat may be rapid, during sleep it might be lower and with exertion, it may be faster. Assessment of Apgar score is made immediately after birth in which one of the five elements is heart rate. Generally, a baby is likely to have a heart rate of 100 plus, if the baby is pink and is breathing with a good tone. By using a stethoscope or fingers, the doctor assesses the newborn's heart rate at delivery. 

Abnormal Results

If the Apgar score is less than 7, then it may mean that the baby needs medical attention. If the Apgar score is less, then it indicates that the baby needs help in order to adjust to the outside world.

Usually a low Apgar score is caused by:

  • Complication in birth
  • C-section
  • Fluid in the baby’s airway 

Such a baby with low Apgar score may need:

  • Help with breathing by providing oxygen and the airway needs to be cleared out
  • Physical stimulation to get the heart beating at a healthy rate.

The one-minute Apgar score is usually low and by 5 minutes. it is near normal. If the Apgar score is low, it does not mean that the baby has long-term health problems or a serious health problem. This test has been designed to help predict the future health of the baby. If the scores are between 1-3, then they are critically low and if they are between 4-6, then they are below normal and the result is normal if the score is above 7. A baby may likely need medical intervention if the score is low. The medical team should be alert to the possibility of intervention if the Apgar score is low.

A baby who has a high Apgar score may not need resuscitation as compared to a baby with low Apgar score. The five factors here are taken into consideration while providing resuscitation to the baby, wherein the baby is provided help with her blood pressure, heart or breathing. Some factors of Apgar score are subjective in nature. Hence the score may be high, but nonetheless it is obvious that medical treatment is needed for the baby.

At times after 10, 15, or 30 minutes, the score may be low after birth. There may be a high possibility of long term neurological damage or there is possibility of cerebral palsy although the possibility of this risk is less. However if the Apgar score is high, then it does not mean that the baby does not have any brain injury. Through Apgar score, one can determine whether immediate medical care is needed by a newborn. Apgar score has not been designed to make long term prediction about the health of the baby.

Studies done on the Apgar score have shown that this test is fairly reliable and may indicate that the infant has good chances of survival. However, all possible complications cannot be checked by the Apgar score. Moreover, it also does not guarantee that the baby will have a completely positive outlook.